Laserfiche WebLink
<br />CITY'OF CENTERVILLE . <br />INTOXICATION MALT LIQUOR LICENSE <br />APPLICATION <br />DRAM SHOP INSURANCE EXEMPTION <br /> <br />I hereby certify under penalty of peIjury that I have applied for an intoxicating liquor/on- <br />sale wine license and that the sales of such beverages are less than $10,000 per year. In <br />addition. I certify that the attached list of mv wholesale suppliers is true and correct. If <br />necessary, these suppliers may be contacted in order to confinn this declaration. <br /> <br /> <br />I <br />I <br /> <br />J tJ ..-/6..ro 7 <br />I <br />Date <br /> <br />JI~/.o7 <br />. <br /> <br />I i <br />I I <br />I <br />! I <br /> <br /> <br />//h/()'7 <br />Date' <br /> <br /> <br />KR/S SWEENEY <br />NOTARY PUBLIC. MINNESOTA <br />My Commission Expires Jan. 31, 2010 <br /> <br />I <br />I I <br />I <br /> <br />NOTE: A LIST OF YOUR WHOLESALE SUPPLIERS MUST ACCOMPANY THIS <br />DRAM SHOP EXEMPTION FORM. <br />fl/ll/JJ/.A1I1 /);!-f, 139- Jidj <br />}1fJ/-ptil ~1{I/V - 6J J- ) Jf - Y?7fj <br />Xi. fA'rJII - 6~ 1- 'It)./ JJ3 <br />JIIe (}IJIliA tD'" 61 J ..339.. 5'10d. <br />(Y)AIIJ( "fIT - 6J J - b16 - 61J6J <br />J(JktVJo;JA/) oS .. 6Y?-S'iOO <br />